Instructions: Complete this form and select "print".
The latest (2015+) Michigan Medical Marihuana new Application form will be printed with the information you have added.
Bring this form with you to your local certification center
- What information does MMF collect from me?MMF may collect personal and personally identifiable information from you when use the Software (“Personal Information”). This includes:
- Email address;
- First name and surname;
- Phone number or fax number;
- Address, city, state, and zip code;
- Information needed to complete a payment; and
- Any other information that you voluntarily submit to the Software.
- Information collected through first and third party cookies, including, but not limited to, session cookies and persistent cookies;
- IP address;
- Geolocation data;
- Software pages accessed; and
- Your use of the Software
- How does MMF use this information?By using the MMF Software and/or its services, users expressly consent to MMF’s use of user information for any purpose. These uses may include, but are not limited to, providing you with support, to register your User Account, to provide you with the Software or its associated services, to communicate with you about your User Account or purchase order, to transmit this information to a third party, to aid you in completing a transaction, such as purchasing a product, to tailor the Software to your preferences, to change the Software content, and/or to update you on MMF’ services.
- How does MMF secure this information?MMF works to protect the security of your personal and personally identifiable information and has implemented industry standard encryption to protect against unauthorized access to or interception of your personal and personally identifiable information. You are responsible for the security of the username and password associated with your Member Account and you have an ongoing duty to guard against unauthorized access. In the event you discover unauthorized access to your Member Account, you must immediately inform MMF of the details of the unauthorized access.
- Does MMF share this information with third parties? MMF does not sell or rent your personal or personally identifiable information to third parties. MMF may, however, share your personal or personally identifiable inormation, and only to the extent required, with third parties that use the Software in order to provide the services offered through the Software. MMF may also transfer your personal or personally identifiable information to third parties upon your consent.MMF may transfer your personal or personally identifiable information when sharing information with its parents or subsidiaries or to a third party in a sale of the Software or MMF. MMF may also transfer your personal or personally identifiable information to respond to a duly authorized subpoena or court order, to respond to regulatory requests by government authorities, to protect the safety or security of MMF, the Software, its employees, and its users, and, where necessary, to protect against fraud, false advertising, or the violation of any law, statute, ordinance, regulation, or treaty, whether local, state, provincial, national or international.
- How may I cease MMF’s collection and/or use of my personal or personally identifiable information? You have the right to control the collection and use of your Personal Information through the Software by taking voluntary actions. Your input of personally identifiable Personal Information is purely voluntary. Further, you may cease MMF’s collection and use of your Personal Information by discontinuing your use of the Software, and adjusting your web browser settings to clear any cookies remaining on your computer from your prior use of the Software.
- What are my duties when using the Software?When using the Software, you have the duty to immediately update MMF when your personal information changes. You may update your personal information by accessing your User Account. Additionally, you have the duty to protect the security of your User Account, including protecting against unauthorized access to your user account and protecting your username and password. You are advised not to share your username or password with third parties.
MichiganMarijuanaForms.com End User License Agreement
Thank you for downloading and using Michigan Marijuana Forms (“Software”). This End User License Agreement (“Agreement”) is by and between you, the user (“User,” “You,” and “Your”), and Michiganmarijuanaforms.com (“MMF”), a corporation organized under the laws of the State of Michigan. MMF provides You with a limited license to use the Software. Your use of the Software is subject to the terms and conditions of this Agreement.
This Agreement will be effective when You select the “I Agree” button, and Your selection of the “I Agree” button constitutes Your manifestation of assent to the terms of this Agreement. If You do not wish to be bound by the terms of this Agreement, You must not select the “I Agree” button or use the Software.
YOU ACKNOWLEDGE AND AGREE THAT YOUR USE OF THE SOFTWARE CONSTITUTES YOUR CONSENT TO THE TRANSMISSION OF INFORMATION COLLECTED BY THE SOFTWARE TO AND FROM SERVERS OWNED BY, OPERATED BY, OR UNDER THE CONTROL OF MMF. BY USING THE SOFTWARE, YOU EXPRESSLY CONSENT TO THE TRANSMISSION OF THIS INFORMATION. MMF MAY CHANGE THE TERMS OF THIS AGREEMENT AT ANY TIME. IN THE EVENT MMF CHANGES THE TERMS OF THIS AGREEMENT, THE EFFECTIVE DATE ABOVE WILL CHANGE. YOUR CONTINUED USE OF THE SOFTWARE AFTER A CHANGE IN THE EFFECTIVE DATE CONSTITUTES YOUR MANIFESTATION OF ASSENT TO AND AGREEMENT WITH ANY AND ALL CHANGES TO THIS AGREEMENT.
1. Warranties. You warrant and agree that You have the right and legal capacity to enter into this Agreement and to adhere to its terms and conditions. You warrant that you are a human individual that is eighteen (18) years of age or older and that You are not a bot, script, or other computer or machine. You warrant that You are not prohibited from assenting to this Agreement by any preexisting Agreement. If You are using the Website on behalf of a third party, including but not limited to a business entity, You warrant that You are the authorized representative of that third party and have the authority to bind that third party to the terms of this Agreement.
2. User Account. MMF may provide You with the ability to register a user account (“User Account”), which will provide access to the Software. Some User Accounts provide additional access to premium features (“Clinic Accounts”). Your User Account is protected by a username and password. You recognize that You are solely responsible for maintaining the security and confidentiality of Your username and password and that You are responsible for any unauthorized access to Your User Account. In the event Your User Account is accessed without Your authorization, You agree to notify MMF immediately. MMF reserves the right to restrict access to, suspend, disable, or delete Your User Account at any time, in its sole discretion, and without prior warning.
3. Limited License. Subject to the terms of this Agreement and conditional upon payment for a User Account, MMF grants You a limited, non-exclusive, non-transferable, worldwide, and revocable license to use the Software in executable form and for its customary and intended purposes.
4. License Conditions. As a condition of the license granted to You under the terms of this Agreement, and except where otherwise expressly allowed under the terms of this Agreement, You are expressly prohibited from the following:
a) Distributing, emulating, cloning, publishing, displaying, selling, assigning, sublicensing, renting, leasing, loaning, modifying, publicly displaying, publicly performing, creating derivative works of, translating, or adapting the Software; b) Decompiling, reverse engineering, disassembling, or hacking the Software; c) Circumventing the Software’s technology protection measures; d) Infringing upon the intellectual property or other proprietary rights of MMF; e) Exporting the Software in violation of the export controls and regulations of the laws of the United States or any other applicable country’s laws or regulations; f) Using the Software to violate any applicable law, statute, regulation, ordinance, or treaty, whether national or international; g) Using the Software to violate the rights of third parties, including, but not limited to, personal or proprietary rights; h) Removing or altering any proprietary notices contained within the Software, including, but not limited to, copyright and trademark notices; and i) Distributing, copying, emulating, cloning, selling, modifying, decompiling, disassembling, or otherwise reverse engineering the Software.
You understand and agree that You are prohibited from using the Software in any way inconsistent with or in violation of this Agreement or any local, state, national, or international laws or regulations.
5. Payment. When You register and use a Clinic Account to access the Software, You agreed to be charged a user fee (“Clinic Fee”) by MMF. The Clinic Fee will be payable at the times specified by MMF in the Software and on a reoccurring basis. Specifically, You will be charged as follows: a. $250 per month for 50 completed applications, defined as completing the required information and clicking the “download and print” call to action (“Completed Application”); b. Additional patients in a one-month period are charged $5 per Completed Application with payment being charged at mutually agreed upon times or the end of the each month;
All Clinic Fee payments for the Software are non-refundable. You represent and warrant that You will timely pay all fees and charges and You agree that MMF will charge Your payment method on a reoccurring basis. MMF reserves the right to terminate Your User Account and access to the Software for Your failure to timely pay. All Clinic Fees will be quoted and payable in United States Dollars. You agree that You will not initiate any chargebacks against MMF unless approved by MMF in writing. You understand and agree that You will be held responsible for any costs or fees associated with any unauthorized chargebacks. Any disputes as to payment must be brought to MMF’s attention in writing within thirty (30) days or will otherwise be barred. MMF reserves the right to adjust pricing for its services or any components thereof in any manner and at any time as it may determine in its sole and absolute discretion.
You may cancel your User Account at any time. MMF DOES NOT PROVIDE REFUNDS OR CREDITS FOR ANY PARTIAL-MONTH/YEAR USER ACCOUNTS PERIODS OR UNUSED SERVICES.
6. Acceptable Use Policy. You are expressly prohibited from using the Software to violate any law, statute, ordinance, regulation, or treaty, whether local, state, provincial, national or international, or to violate the rights of a third party, including, but not limited to, intellectual property rights, privacy rights, rights of publicity, or other personal or proprietary rights.
8. Health Insurance Portability and Accountability Act (HIPAA). HIPAA is a United State Federal Law aimed, in part, at protecting the confidentiality and security of healthcare information. Specifically, it is designed to regulate the uncontrolled flow of patients’ health information, including when a healthcare provider transfers information to third-party billing services. HIPAA requires “covered entities” to comply with the Act’s Privacy Rule, which protects the privacy of certain individually identifiable health information, and grants individuals certain rights regarding their health information. Covered entities include health care providers, health care clearinghouses, and health plans. Since MMF is none of these, but rather a web-based Software As A Service platform, it is not a covered entity under the Act.
The MMF is not HIPPA compliant. Anyone using the Software, including patients, physicians, caregivers, or any other person, individual, or entity is solely responsible for complying with any and all federal, state, or local laws governing the storage of any private or health information. MMF specifically disclaims that its Software is HIPPA compliant. Anyone using this Software requiring storage of “protected health information” as defined under HIPPA is strictly prohibited from using the Software.
Notwithstanding provisions to the contrary, MMF may disclose protected health information in compliance with a court order. In the event that this occurs, MMF will notify the user to give them an opportunity to object to the request.
If you have any questions or concerns about your health records, you should contact MMF’ privacy office in writing at firstname.lastname@example.org.
9. Error Reporting and Feedback. In the event You provide feedback or suggestions to MMF on any performance issues, bugs, defects, errors, omissions, improvements, test results, or any other performance or operational issues that relate to or arise out of Your use of the Software, You understand and agree this feedback or suggestions, including any intellectual property or other proprietary information contained within, will become the exclusive property of MMF and You agree to assign all right and title in or to any and all feedback or suggestions that You submit to MMF. You further agree to execute any and all documents necessary to assign Your rights to any and all feedback or suggestions submitted to MMF upon MMF’s request, including, but not limited to, any documents necessary to perfect MMF’s rights in and to intellectual property rights.
10. Proprietary Rights. You understand and agree that the Software, including, but not limited to, its source code, selection and arrangement, executable code, structure, and organization contains the valuable trade secrets and intellectual property of MMF. Under the terms of this Agreement, You do not acquire any ownership rights in or to the Software. You acquire only a limited license to use the Software subject to the terms of this Agreement. All other rights are reserved by MMF.
11. Trademarks. You acknowledge and agree that any and all trademarks, trade names, design marks, or logos displayed on or through the Software, including, but not limited to, MICHIGAN MEDICAL MARIJUANA FORMS and MMF, are common law or registered trademarks owned by or licensed to MMF. You are expressly prohibited from using the trademarks of MMF to cause confusion in, to cause mistake in, or to deceive consumers, or from falsely designating the origin of, the source of, or the sponsorship of Your goods or services. You are further prohibited from using the trademarks of MMF in domain names, in keyword advertisements, to trigger keyword advertisements, or in meta tags. All other trademarks, trade names, design marks, or logos are the property of their respective owners.
12. Term and Termination. The term of this Agreement will begin upon Your first accessing of the Software and will continue until the earlier of the following: (i) MMF terminates Your access to the Software; or (ii) You cease using the Software and terminate Your User Account. MMF reserves the right to terminate the Software or Your access to the Software in its sole and absolute discretion and without prior notice.
13. Termination. Any license granted under the terms of this Agreement will remain in effect for its full term unless terminated earlier by one of the following actions:
a) Your breach of any term or condition of this Agreement; b) Your failure to pay any monies owed MMF for any license granted under this Agreement or otherwise; c) If either Party to this Agreement is adjudicated as bankrupt under the U.S. Bankruptcy Code, as now constituted or later amended, or under any other applicable federal or state bankruptcy law or other similar law, or an assignment of a receiver, liquidator, assignee, trustee, custodian (or similar official) of either Party to this Agreement or any substantial part of their properties, or on the winding up of or liquidation of the affairs of either of the Parties to this Agreement, the other Party will be entitled at its own discretion to terminate any license granted under this Agreement forthwith by written notification to the Party concerned; and d) Upon either Party’s violation of any applicable law, statute, regulation, ordinance, or treaty, whether national or international.
14. Assignment. The rights granted in this Agreement are restricted for use solely by You and may not be assigned, transferred, or sublicensed. MMF may assign its rights and duties under this Agreement at any time, including, but not limited to, in a sale of the assets of MMF or in a sale of the company itself.
15. Disclaimer of Warranties and Limitation of Liability. YOU ACKNOWLEDGE AND AGREE THAT THE MMF SOFTWARE IS PROVIDED ON AN “AS-IS” BASIS AND WITHOUT WARRANTY OF ANY KIND, INCLUDING, BUT NOT LIMITED TO, WARRANTIES OF TITLE, MERCHANTABILITY, ACCURACY, FITNESS FOR A PARTICULAR PURPOSE, SECURITY, AND NON-INFRINGEMENT. WHEREVER PERMITTED BY LAW, YOU ACKNOWLEDGE THAT MMF WILL NOT BE HELD RESPONSIBLE OR LIABLE FOR ANY CLAIMS, DAMAGES, JUDGMENTS, CHARGES, OR FEES ARISING OUT OF OR RELATED TO YOUR USE OF OR ACCESS TO THE MMF SOFTWARE, INCLUDING, BUT NOT LIMITED TO, COMPENSATORY DAMAGES, CONSEQUENTIAL DAMAGES, SPECIAL DAMAGES, INCIDENTAL DAMAGES, PUNITIVE DAMAGES, EXEMPLARY DAMAGES, COSTS AND ATTORNEYS’ FEES, DAMAGES ARISING OUT OF ERRORS OR OMISSIONS, AND DAMAGES ARISING OUT OF THE UNAVAILABILITY OF THE WEBSITE OR DOWNTIME. YOU ACKNOWLEDGE THAT MMF OBTAINS ITS DATA FROM PUBLIC SOURCES AND THAT MMF WILL NOT BE HELD LIABLE OR RESPONSIBLE FOR ANY ERRORS IN THE DATA DISPLAYED THROUGH THE MMF SOFTWARE. YOU ACKNOWLEDGE THAT YOUR USE OF THE MMF SOFTWARE IS AT YOUR SOLE RISK AND THAT MMF’S LIABILITY IS LIMITED TO THE AMOUNT THAT YOU PAID TO USE THE MMF SOFTWARE OR $1,000, WHICHEVER IS LESS.
SOME STATES OR PROVINCES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF DAMAGES. IF YOUR STATE OR PROVINCE DOES NOT ALLOW THE EXCLUSION OR LIMITATION OF DAMAGES, YOU SHOULD SEEK LEGAL COUNSEL TO UNDERSTAND YOUR RIGHTS UNDER THE LAW.
16. Indemnification. You agree to indemnify, defend, and hold harmless MMF, its officers, shareholders, directors, employees, subsidiaries, affiliates, and representatives, from any and all losses, including, but not limited to, costs and attorneys' fees, arising out of or related to (i) Your use of the Software, (ii) Your violation of any term or condition of this Agreement; (iii) Your violation of the rights of third parties, including, but not limited to, intellectual property rights or other personal or proprietary rights; and (iv) violation of any law, statute, ordinance, regulation, or treaty, whether local, state, provincial, national or international. Your obligation to defend MMF will not provide You with the ability to control MMF’s defense, and MMF reserves the right to control its defense, including its choice of counsel and whether to litigate or settle a claim subject to indemnification.
17. Governing Law and Choice of Forum. This Agreement will be governed by and interpreted in accordance with the laws of the State of Michigan and the federal law of the United States of America, without regard to the conflicts of laws rules thereof.
YOU AND MMF AGREE THAT ARBITRATION WILL BE THE EXCLUSIVE FORUM AND REMEDY AT LAW FOR ANY DISPUTES ARISING OUT OF OR IN RELATION TO THIS AGREEMENT OR CONCERNING THE VALIDITY, INTERPRETATION, BREACH, VIOLATION, OR TERMINATION OF THIS AGREEMENT. THIS ARBITRATION WILL BE HELD IN TRAVERSE CITY, MICHIGAN AND WILL BE HELD IN ACCORDANCE WITH THE MOST RECENTLY EFFECTIVE COMMERCIAL ARBITRATION RULES OF THE AMERICAN ARBITRATION ASSOCIATION. THE ARBITRATOR WILL DECIDE THE CLAIM ON THE BASIS OF THE LEGAL PRINCIPLES AND LAWS OF THE STATE OF MICHIGAN AND WILL HAVE THE DISCRETION TO AWARD ALL COSTS AND ATTORNEYS’ FEES. THE LOSING PARTY WILL BE REQUIRED TO PAY THE PREVAILING PARTY’S REASONABLE ATTORNEYS’ FEES. YOU AND MMF AGREE THAT THE DETERMINATION OR AWARD OF THIS ARBITRATOR MAY BE ENTERED AS A JUDGMENT IN ANY COURT SITTING WITHIN THE STATE OF MICHIGAN THAT HAS JURISDICTION OVER THE SUBJECT MATTER OF THE DISPUTE. YOU AND MMF AGREE THAT THE PARTIES WILL BE REQUIRED TO BE PRESENT WITHIN THE STATE OF MICHIGAN IN ORDER TO PERFORM THEIR OBLIGATIONS UNDER THIS AGREEMENT. YOU AND MMF HEREBY AGREE TO SUBMIT TO THE EXCLUSIVE PERSONAL AND SUBJECT MATTER JURISDICTION OF ANY SUCH ARBITRATOR OR ARBITRATION PROCEEDING.
18. Notices. Unless otherwise specified in this Agreement, any notices required or permitted to be given to MMF pursuant to this Agreement will be in writing and will be deemed to have been given when received at:Revision Legal, PLLC 148 E. Front St. Traverse City, MI 49684
19. Force Majeure. MMF will not responsible for any delay or failure in performance of the Software arising out of any cause beyond MMF’s control, such as acts of God, war, riots, fire, terrorist attacks, power outages, severe weather, or other accidents.
20. Severability. If any provision of this Agreement or the application thereof to any person or circumstance is found to be invalid, illegal, or unenforceable to any extent, the remainder of this Agreement and the application thereof will not be affected and will be enforceable to the fullest extent permitted by law.
21. Waiver and Integration. No term or condition of this Agreement or breach of this Agreement will be deemed to have been waived or consented to unless said waiver is in writing and signed by the party to be charged. This Agreement is the entire agreement between the parties and supersedes all previous agreements or representations between the parties.
22. Interpretation. This Agreement will be deemed to have been drafted by both parties and the terms and conditions of this Agreement will not be interpreted against its drafter.
23. Survivability. The representations, warranties, duties, and covenants made by You under this Agreement will survive the termination of this Agreement and Your use of the Software including, but not limited to, Your duty to indemnify and defend MMF.
MichiganMedicalMarijuanaForms is © MMF 2015. All rights reserved.